NURSING HEALTH ASSESSMENT 3rd Edition By Dillon – Test Bank A+

$35.00
NURSING HEALTH ASSESSMENT 3rd Edition By Dillon – Test Bank A+

NURSING HEALTH ASSESSMENT 3rd Edition By Dillon – Test Bank A+

$35.00
NURSING HEALTH ASSESSMENT 3rd Edition By Dillon – Test Bank A+

Identify the choice that best completes the statement or answers the question.

____ 1. The S1 heart sound is made during which part of the cardiac cycle?

1)Systolic
2)Diastolic
3)Early diastolic
4)Midsystolic

____ 2. The nurse auscultates a widely split S2 heart sound. Which is this assessment finding indicative of?

1)Atrial fibrillation
2)Left bundle branch block (LBBB)
3)Right bundle branch block (RBBB)
4)Ventricular fibrillation

____ 3. The nurse auscultates an S3 gallop rhythm in an adult. Which disorder is this indicative of?

1)Atrial fibrillation
2)Heart failure
3)Ventricular tachycardia
4)Atrial septal defect

____ 4. Turbulent blood flow within the heart is heard as a murmur. Which is the cause of the murmur?

1)Increased blood volume
2)Constricted blood vessels
3)Flow from a normal vessel to a dilated one
4)All of the above

____ 5. Ethnic variations have an impact on severity of coronary artery disease (CAD). Which individual is more likely to suffer from CAD?

1)Japanese American male
2)Puerto Rican female
3)African American female
4)White female

____ 6. The nurse auscultates an S2 sound during a cardiovascular system assessment. Which conclusion by the nurse is most appropriate?

1)Normal finding
2)Mitral valve stenosis
3)Pericarditis
4)Hypertension

____ 7. Which location does the nurse use to assess S1?

1)Base left
2)Base right
3)Apex
4)Left lower sternal border

____ 8. The nurse notes an opening snap when auscultating a patient’s heart sounds. Which does this finding indicate?

1)Atrial fibrillation
2)Pulmonary hypertension
3)Emphysema
4)Mitral stenosis

____ 9. The S3 rhythm often accompanies which heart problem?

1)Heart failure
2)Mitral stenosis
3)Pulmonary hypertension
4)Myocardial infarction (MI)

____ 10. Which heart problem is responsible for an early systolic murmur?

1)Pericarditis
2)Turbulent venous flow
3)Ventricular septal defect (VSD)
4)Myocardial infarction (MI)

____ 11. Which is often the cause of an additional heart sound heard during pregnancy?

1)A mammary soufflé
2)Friction rub
3)Venous hum
4)S4 gallop

____ 12. Which of the following factors may affect a patient’s risk for heart disease?

1)Age
2)Gender
3)Ethnicity
4)All of the above

____ 13. To measure jugular venous pressure, the patient should be placed in which position?

1)Supine
2)High Fowler’s
3)Semi-Fowler’s
4)Prone

____ 14. Which action by the nurse will allow bruits to be heard most accurately?

1)Using a fetoscope
2)Using the diaphragm of the stethoscope
3)Using the bell of the stethoscope
4)Using the unassisted ear

____ 15. An older adult patient is admitted to the critical care unit with uncontrolled hypertension. The patient’s point of maximal impulse (PMI) is enlarged and displaced laterally. Which is the normal size of the left ventricular impulse (LVI)?

1)<1 cm
2)No greater than 2 cm
3)Between 3 and 4 cm
4)>4 cm

____ 16. The nurse notes an elevated jugular venous pressure (JVP). Which disease process can cause this assessment finding?

1)Hypovolemia
2)Constrictive pericarditis
3)Right ventricular hypertrophy
4)Abnormal venous wave forms

____ 17. The nurse is assessing a patient’s heart sounds. Which pitch is expected for the S2 sound?

1)Vibrating
2)Grating
3)Low
4)High

____ 18. At which auscultatory site would S1 best be heard?

1)Aortic
2)Pulmonic
3)Erb point
4)Mitral

____ 19. At which auscultatory site would S2 best be heard?

1)Mitral
2)Tricuspid
3)Erb point
4)Aortic area

____ 20. The nurse detects a widely abnormal split S2. At which auscultatory site would this be heard?

1)Aortic
2)Pulmonic
3)Tricuspid
4)Mitral

____ 21. At which auscultatory site would a normal split S1 occur?

1)Aortic
2)Pulmonic
3)Tricuspid
4)Mitral

____ 22. Which extra heart sound might the nurse anticipate for a patient with a history of hypertension?

1)S3
2)S4
3)Ejection click
4)Opening snap

____ 23. When auscultating heart sounds, what is the best way to differentiate S1 and S2?

1)Time S1 with a visible pulsation at the apex
2)Time S1 with the carotid pulsation
3)Time S1 as the louder sound at the base
4)Time the difference between S1 and S2 and the next S1

____ 24. The nurse is preparing to conduct a cardiovascular assessment. Which piece of equipment is not required?

1)Stethoscope
2)Pen light
3)Scale
4)Otoscope

____ 25. Which finding is abnormal when conducting inspection as part of a cardiovascular assessment?

1)Visible carotid pulsations
2)No neck vein distention
3)Large pulsations in the neck
4)Positive pulsation at the apex

____ 26. The nurse assesses an S4 gallop rhythm during a cardiovascular assessment. Which is the reason for this heart sound?

1)Pulmonary hypertension
2)Mitral stenosis
3)Aortic stenosis
4)Pericarditis

____ 27. The nurse notes a low-pitch early systolic murmur during a cardiovascular assessment. Which quality will the nurse document when recording this murmur in the patient’s medical record?

1)Rough
2)Harsh
3)Blowing
4)Rumbling

Completion

Complete each statement.

  1. The nurse knows that a systolic murmur less than or equal to a grade ____________________ auscultated during a cardiovascular assessment is usually innocent.

  1. Diastolic murmurs or murmurs greater than or equal to a grade ____________________ are usually significant of pathology.

  1. An S3 heart sound may be a normal finding in patients younger than ____________________ years of age.

  1. Native Americans younger than ____________________ years have twice the mortality rate from heart disease as other groups.

  1. The nurse is preparing to assess the apical pulse, which is found in the ____________________th intercostal space.

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

____ 33. The nurse is preparing to conduct a cardiovascular assessment. Which positions are appropriate for the patient to assume during cardiac auscultation? Select all that apply.

1)Sitting
2)Trendelenburg
3)Supine
4)Sims’
5)Left lateral recumbent

____ 34. The nurse educator is teaching a group of nursing students about jugular pulsations. Which statements will the educator include in the presentation? Select all that apply.

1)“Jugular pulsations are easily obliterated.”
2)“Jugular pulsations are affected by position.”
3)“Jugular pulsations are affected by respirations.”
4)“Jugular pulsations are affected by weight.”
5)“Jugular pulsations are assessed with a stethoscope.”

____ 35. The nurse is conducting a health history for a patient who presents for a cardiovascular assessment. Which drugs would likely cause the patient’s heart rate to be more than 100 beats per minute? Select all that apply.

1)Nitrates
2)Isoproterenol
3)Nicotine
4)Digoxin
5)Procainamide

____ 36. The nurse is assessing a patient who presents with a heart rate of less than 60 beats per minute. Which are possible causes for this assessment finding? Select all that apply.

1)Sinus bradycardia
2)Atrial fibrillation
3)Heart block
4)Myocardial infarction
5)Hyperkalemia

____ 37. The nurse notes mitral regurgitation during auscultation of heart sounds. Which are characteristic of this finding? Select all that apply.

1)Best auscultated at apical area
2)Described as blowing, harsh, or musical
3)May mask S1
4)Localized to a small area
5)Described as a rough, low-pitched sound

Chapter 06: Assessing the Cardiovascular System

Answer Section

MULTIPLE CHOICE

  1. ANS: 1

Chapter number and title: 6, Assessing the Cardiovascular System

Chapter learning objective: N/A

Chapter page reference: 202

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Comprehension [Understanding]

Concept: Assessment, Perfusion

Difficulty: Easy

Feedback
1S1 occurs during systole.
2S1 does not occur during diastole.
3S1 does not occur during early diastole.
4S1 does not occur during midsystole.

PTS: 1 CON: Assessment | Perfusion

  1. ANS: 3

Chapter number and title: 6, Assessing the Cardiovascular System

Chapter learning objective: N/A

Chapter page reference:

Heading: 202

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Comprehension [Understanding]

Concept: Perfusion

Difficulty: Moderate

Feedback
1A split R2 does not indicate atrial fibrillation.
2A split R2 does not indicate LBBB.
3A split R2 often indicates RBBB.
4A split R2 does not indicate ventricular fibrillation.

PTS: 1 CON: Perfusion

  1. ANS: 2

Chapter number and title: 6, Assessing the Cardiovascular System

Chapter learning objective: N/A

Chapter page reference: 192

Integrated Processes: Nursing Process: Evaluation

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Evaluation [Evaluating]

Concept: Perfusion

Difficulty: Moderate

Feedback
1The S3 gallop rhythm is not indicative of atrial fibrillation.
2The S3 gallop rhythm is a sign of congestive heart failure (CHF). It relates to hemodynamic filling of a failing, noncompliant ventricle.
3The S3 gallop rhythm is not indicative of ventricular tachycardia.
4The S3 gallop rhythm is not indicative of atrial septal defect.

PTS: 1 CON: Perfusion

  1. ANS: 4

Chapter number and title: 6, Assessing the Cardiovascular System

Chapter learning objective: N/A

Chapter page reference: 203

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Comprehension [Understanding]

Concept: Perfusion

Difficulty: Moderate

Feedback
1Murmurs can be caused by increased blood volume.
2Murmurs can be caused by constricted blood vessels.
3Murmurs can be caused by flow from a constricted blood vessel to a dilated blood vessel.
4Murmurs are defined as a series of audible, prolonged sounds resulting from turbulence created within the vascular system. Causes of turbulent flow include increased flow through normal blood vessels creating frictional, audible sounds; flow through constricted blood vessels (as in aortic stenosis); flow into a dilated blood vessel from one of normal size; or a combination of these.

PTS: 1 CON: Perfusion

  1. ANS: 3

Chapter number and title: 6, Assessing the Cardiovascular System

Chapter learning objective: N/A

Chapter page reference: 173

Integrated Processes: Nursing Process: Planning

Client Need: Health Promotion and Maintenance

Cognitive level: Knowledge [Remembering]

Concept: Diversity

Difficulty: Easy

Feedback
1Japanese and Puerto Ricans have a lower incidence of hypertension and high cholesterol; middle-aged white males have the highest incidence of CAD.
2Japanese and Puerto Ricans have a lower incidence of hypertension and high cholesterol; middle-aged white males have the highest incidence of CAD.
3African Americans have an earlier onset and greater severity of CAD than other groups; African American women have a greater incidence of CAD than white women.
4African American women have a greater incidence of CAD than white women.

PTS: 1 CON: Diversity

  1. ANS: 1

Chapter number and title: 6, Assessing the Cardiovascular System

Chapter learning objective: N/A

Chapter page reference: 202

Integrated Processes: Nursing Process: Evaluation

Client Need: Health Promotion and Maintenance

Cognitive level: Analysis [Analyzing]

Concept: Perfusion

Difficulty: Moderate

Feedback
1S2 is a normal finding when auscultating the chest during a cardiovascular assessment.
2S2 does not indicate mitral valve stenosis.
3S2 does not indicate pericarditis.
4S2 does not indicate hypertension.

PTS: 1 CON: Perfusion

  1. ANS: 3

Chapter number and title: 6, Assessing the Cardiovascular System

Chapter learning objective: N/A

Chapter page reference: 202

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Application [Applying]

Concept: Assessment

Difficulty: Moderate

Feedback
1S1 is not auscultated at the left base.
2S1 is not auscultated at the right base.
3The nurse auscultates S1 at the apex.
4S1 is not auscultated at the left lower sternal border.

PTS: 1 CON: Assessment

  1. ANS: 4

Chapter number and title: 6, Assessing the Cardiovascular System

Chapter learning objective: N/A

Chapter page reference: 202

Integrated Processes: Nursing Process: Evaluation

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Evaluation [Evaluating]

Concept: Perfusion, Assessment

Difficulty: Moderate

Feedback
1An opening snap is not a heart sound that is indicative of atrial fibrillation.
2An opening snap is not a heart sound that is indicative of pulmonary hypertension.
3An opening snap is not a heart sound that is indicative of emphysema.
4An opening snap is a heart sound that occurs for patients diagnosed with mitral stenosis.

PTS: 1 CON: Perfusion | Assessment

  1. ANS: 1

Chapter number and title: 6, Assessing the Cardiovascular System

Chapter learning objective: N/A

Chapter page reference: 202

Integrated Processes: Nursing Process: Evaluation

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Evaluation [Evaluating]

Concept: Perfusion, Assessment

Difficulty: Moderate

Feedback
1An S3 in an adult is a sign of a failing heart. The S3 rhythm often accompanies heart failure.
2An S3 in an adult is not indicative of mitral stenosis.
3An S3 in an adult is not indicative of pulmonary hypertension.
4An S3 in an adult is not indicative of an MI.

PTS: 1 CON: Perfusion | Assessment

  1. ANS: 3

Chapter number and title: 6, Assessing the Cardiovascular System

Chapter learning objective: N/A

Chapter page reference: 192

Integrated Processes: Nursing Process: Evaluation

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Analysis [Analyzing]

Concept: Perfusion

Difficulty: Moderate

Feedback
1An early systolic murmur is not caused by pericarditis.
2An early systolic murmur is not caused by turbulent venous flow.
3An early systolic murmur can be caused by VSD.
4An early systolic murmur is not caused by an MI.

PTS: 1 CON: Perfusion

  1. ANS: 1

Chapter number and title: 6, Assessing the Cardiovascular System

Chapter learning objective: N/A

Chapter page reference: 172

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Knowledge [Remembering]

Concept: Pregnancy, Perfusion

Difficulty: Easy

Feedback
1A mammary soufflé is a murmur that develops from increased blood flow through the mammary artery, occurring late in pregnancy or during lactation.
2A friction rub is an abnormal finding.
3A venous hum is an abnormal finding.
4An S4 gallop is an abnormal finding.

PTS: 1 CON: Pregnancy | Perfusion

  1. ANS: 4

Chapter number and title: 6, Assessing the Cardiovascular System

Chapter learning objective: N/A

Chapter page reference: 173

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Knowledge [Remembering]

Concept: Assessment, Perfusion

Difficulty: Easy

Feedback
1The risk for cardiovascular disease increases with age.
2Men have a greater incidence of cardiovascular disease than women. Women have a higher mortality rate within 1 year post-MI than men.
3Certain cardiovascular diseases are more prevalent in specific races or ethnic backgrounds.
4The risk for cardiovascular disease increases with age. Men have a greater incidence of cardiovascular disease than women. Women have a higher mortality rate within 1 year post-MI than men. Certain cardiovascular diseases are more prevalent in specific races or ethnic backgrounds.

PTS: 1 CON: Assessment | Perfusion

  1. ANS: 3

Chapter number and title: 6, Assessing the Cardiovascular System

Chapter learning objective: N/A

Chapter page reference: 184

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Application [Applying]

Concept: Assessment, Perfusion

Difficulty: Moderate

Feedback
1The patient is not placed in a supine position to measure jugular venous pressure.
2The patient is not placed in a high Fowler’s position to measure jugular venous pressure.
3To measure jugular venous pressure, elevate the patient’s head to 30 to 45 degrees.
4The patient is not placed in a prone position to measure jugular venous pressure.

PTS: 1 CON: Assessment | Perfusion

  1. ANS: 3

Chapter number and title: 6, Assessing the Cardiovascular System

Chapter learning objective: N/A

Chapter page reference: 190

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Application [Applying]

Concept: Assessment

Difficulty: Moderate

Feedback
1The fetoscope is best for detecting fetal heart sounds.
2The diaphragm is best for detecting high-pitch sounds.
3Bruits are low-pitch sounds heard best with the bell portion of the stethoscope.
4A stethoscope must be used to assess a bruit.

PTS: 1 CON: Assessment

  1. ANS: 2

Chapter number and title: 6, Assessing the Cardiovascular System

Chapter learning objective: N/A

Chapter page reference: 187

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Analyzing [Analysis]

Concept: Perfusion, Assessment

Difficulty: Difficult

Feedback
1The normal side of the PMI (also referred to as the LVI) is 1 to 2 cm.
2The LVI (PMI) is normally no greater than 2 cm at the apex.
3A PMI > 2 cm may indicate ventricular hypertrophy.
4A PMI > 2 cm may indicate ventricular hypertrophy.

PTS: 1 CON: Perfusion | Assessment

  1. ANS: 2

Chapter number and title: 6, Assessing the Cardiovascular System

Chapter learning objective: N/A

Chapter page reference: 184

Integrated Processes: Nursing Process: Evaluation

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Comprehension [Understanding]

Concept: Perfusion, Assessment

Difficulty: Easy

Feedback
1Hypovolemia causes a low JVP.
2Constrictive pericarditis can cause an elevated JVP.
3Right ventricular hypertrophy causes giant A waves.
4Abnormal venous wave forms cause a low JVP.

PTS: 1 CON: Perfusion | Assessment

  1. ANS: 4

Chapter number and title: 6, Assessing the Cardiovascular System

Chapter learning objective: N/A

Chapter page reference: 202

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Knowledge [Remembering]

Concept: Assessment, Perfusion

Difficulty: Easy

Feedback
1The pitch of the S2 sound is not vibrating.
2The pitch of the S2 sound is not grating.
3The pitch of the S2 sound is not low.
4The pitch of the S2 sound is high.

PTS: 1 CON: Assessment | Perfusion

  1. ANS: 4

Chapter number and title: 6, Assessing the Cardiovascular System

Chapter learning objective: N/A

Chapter page reference: 202

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Application [Applying]

Concept: Perfusion, Assessment

Difficulty: Moderate

Feedback
1S2 is heard best at the base or aortic area.
2S2 split is heard at the pulmonic area.
3An early diastolic murmur is best heard at Erb point.
4S1 is the closure of M1 and T1 and is heard best at the apex (mitral area).

PTS: 1 CON: Perfusion | Assessment

  1. ANS: 4

Chapter number and title: 6, Assessing the Cardiovascular System

Chapter learning objective: N/A

Chapter page reference: 202

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Application [Applying]

Concept: Perfusion, Assessment

Difficulty: Moderate

Feedback
1S1 is best heard at the apex.
2S1 split is best heard at the LLSB/tricuspid area.
3An early diastolic murmur is best heard at the Erb point.
4S2 is the closure of A2 and P2 and is heard best at base right (aortic area) and base left (pulmonic area).

PTS: 1 CON: Perfusion | Assessment

  1. ANS: 2

Chapter number and title: 6, Assessing the Cardiovascular System

Chapter learning objective: N/A

Chapter page reference: 202

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Application [Applying]

Concept: Perfusion, Assessment

Difficulty: Moderate

Feedback
1A widely split S2 is not auscultated in the aortic area.
2A widely split S2 is auscultated in the pulmonic area.
3A widely split S2 is not auscultated in the tricuspid area.
4A widely split S2 is not auscultated in the mitral area.

PTS: 1 CON: Perfusion | Assessment

  1. ANS: 3

Chapter number and title: 6, Assessing the Cardiovascular System

Chapter learning objective: N/A

Chapter page reference: 202

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Comprehension [Understanding]

Concept: Perfusion, Assessment

Difficulty: Easy

Feedback
1A normal split S1 does not occur at the aortic site.
2A normal split S1 does not occur at the pulmonic site.
3A normal split S1 occurs at the tricuspid site.
4A normal split S1 does not occur at the mitral site.

PTS: 1 CON: Perfusion | Assessment

  1. ANS: 2

Chapter number and title: 6, Assessing the Cardiovascular System

Chapter learning objective: N/A

Chapter page reference: 202

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Synthesis [Creating]

Concept: Perfusion, Assessment

Difficulty: Difficult

Feedback
1S3 gallop is associated with congestive heart failure (CHF)
2S4 gallop may be associated with hypertension.
3An ejection click is associated with aortic or pulmonic stenosis and mitral valve prolapse.
4An opening snap is associated with mitral or tricuspid stenosis.

PTS: 1 CON: Perfusion | Assessment

  1. ANS: 4

Chapter number and title: 6, Assessing the Cardiovascular System

Chapter learning objective: N/A

Chapter page reference: 192

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Synthesis [Creating]

Concept: Perfusion, Assessment

Difficulty: Moderate

Feedback
1Timing S1 with a visible pulsation at the apex is not an appropriate action to differentiate S1 and S2.
2Timing S1 with the carotid pulsation is not an appropriate action to differentiate S1 and S2.
3Timing S1 as the louder sound at the base is not an appropriate action to differentiate S1 and S2.
4The best way to differentiate S1 and S2 is to establish the timing of the sounds. The shorter timing is between S1 and S2, and the longer timing is between S2 and the next S1.

PTS: 1 CON: Perfusion | Assessment

  1. ANS: 4

Chapter number and title: 6, Assessing the Cardiovascular System

Chapter learning objective: N/A

Chapter page reference: 184

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Comprehension [Understanding]

Concept: Assessment

Difficulty: Easy

Feedback
1A stethoscope is a required piece of equipment when conducting a cardiovascular assessment.
2A pen light is a required piece of equipment when conducting a cardiovascular assessment.
3A scale is a required piece of equipment when conducting a cardiovascular assessment.
4An otoscope is not required when conducting a cardiovascular assessment.

PTS: 1 CON: Assessment

  1. ANS: 3

Chapter number and title: 6, Assessing the Cardiovascular System

Chapter learning objective: N/A

Chapter page reference: 184

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Comprehension [Understanding]

Concept: Assessment, Perfusion

Difficulty: Easy

Feedback
1Visible carotid pulsations is a normal finding.
2No neck vein distention is a normal finding.
3Large pulsations in the neck is an abnormal finding.
4Positive pulsation at the apex is a normal finding.

PTS: 1 CON: Assessment | Perfusion

  1. ANS: 1

Chapter number and title: 6, Assessing the Cardiovascular System

Chapter learning objective: N/A

Chapter page reference: 202

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Application (Applying)

Concept: Assessment, Perfusion

Difficulty: Moderate

Feedback
1An S4 gallop rhythm noted during a cardiovascular assessment is often indicative of pulmonary hypertension.
2An S4 gallop rhythm noted during a cardiovascular assessment is not caused by mitral stenosis.
3An S4 gallop rhythm noted during a cardiovascular assessment is not caused by aortic stenosis.
4An S4 gallop rhythm noted during a cardiovascular assessment is not caused by pericarditis.

PTS: 1 CON: Assessment | Perfusion

  1. ANS: 1

Chapter number and title: 6, Assessing the Cardiovascular System

Chapter learning objective: N/A

Chapter page reference: 203

Integrated Processes: Communication and Documentation

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Application (Applying)

Concept: Assessment, Perfusion

Difficulty: Moderate

Feedback
1The quality of a low-pitch early systolic murmur is rough.
2The quality of a low-pitch early systolic murmur is not harsh.
3The quality of a low-pitch early systolic murmur is not blowing.
4The quality of a low-pitch early systolic murmur is not rumbling.

PTS: 1 CON: Assessment | Perfusion

COMPLETION

  1. ANS:

2

Feedback: Innocent grade 2/6, systolic, blowing murmurs are often heard in children.

Innocent systolic murmurs may also be heard during pregnancy.

Chapter number and title: 6, Assessing the Cardiovascular System

Chapter learning objective: N/A

Chapter page reference: 192

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Comprehension [Understanding]

Concept: Assessment, Perfusion

Difficulty: Easy

PTS: 1 CON: Assessment | Perfusion

  1. ANS:

3

Feedback: A diastolic murmur or a murmur grade 3/6 is never innocent.

Chapter number and title: 6, Assessing the Cardiovascular System

Chapter learning objective: N/A

Chapter page reference: 192

Integrated Processes: Nursing Process: Planning

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Comprehension [Understanding]

Concept: Perfusion, Assessment

Difficulty: Easy

PTS: 1 CON: Perfusion | Assessment

  1. ANS:

30

Feedback: S3 may be normal in people younger than 30 years.

Chapter number and title: 6, Assessing the Cardiovascular System

Chapter learning objective: N/A

Chapter page reference: 202

Integrated Processes: Nursing Process: Planning

Client Need: Health Promotion and Maintenance

Cognitive level: Comprehension [Understanding]

Concept: Assessment, Perfusion

Difficulty: Easy

PTS: 1 CON: Assessment | Perfusion

  1. ANS:

35

Feedback: Native American patients younger than 35 years have twice the mortality rate from heart disease as other groups.

Chapter number and title: 6, Assessing the Cardiovascular System

Chapter learning objective: N/A

Chapter page reference: 173

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Knowledge [Remembering]

Concept: Diversity, Perfusion

Difficulty: Easy

PTS: 1 CON: Diversity | Perfusion

  1. ANS:

5

Feedback: The apical pulse is found in the 5th intercostal space for adult patients.

Chapter number and title: 6, Assessing the Cardiovascular System

Chapter learning objective: N/A

Chapter page reference: 182

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Knowledge [Remembering]

Concept: Assessment, Perfusion

Difficulty: Easy

PTS: 1 CON: Assessment | Perfusion

MULTIPLE RESPONSE

  1. ANS: 1, 3, 5

Chapter number and title: 6, Assessing the Cardiovascular System

Chapter learning objective: N/A

Chapter page reference: 184

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Application [Applying]

Concept: Assessment, Perfusion

Difficulty: Moderate

Feedback
A.A sitting position is often used for cardiac auscultation.
B.A Trendelenburg position is not used for cardiac auscultation.
C.A supine position is used for cardiac auscultation.
D.A Sims’ position is not used for cardiac auscultation.
E.A left lateral recumbent position is used for cardiac auscultation.

PTS: 1 CON: Assessment | Perfusion

  1. ANS: 1, 2, 3

Chapter number and title: 6, Assessing the Cardiovascular System

Chapter learning objective: N/A

Chapter page reference: 184

Integrated Processes: Teaching and Learning

Client Need: Health Promotion and Maintenance

Cognitive level: Application [Applying]

Concept: Perfusion

Difficulty: Moderate

Feedback
A.Jugular pulsations are easily obliterated. This statement is appropriate to include in the teaching presentation.
B.Jugular pulsations are affected by position. This statement is appropriate to include in the teaching presentation.
C.Jugular pulsations are affected by respirations. This statement is appropriate to include in the teaching presentation.
D.Jugular pulsations are not affected by weight. This statement is inappropriate to include in the teaching presentation.
E.Jugular pulsations are not assessed with a stethoscope. This statement is inappropriate to include in the teaching presentation.

PTS: 1 CON: Perfusion

  1. ANS: 1, 2, 3

Chapter number and title: 6, Assessing the Cardiovascular System

Chapter learning objective: N/A

Chapter page reference: 185

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

Cognitive level: Application [Applying]

Concept: Perfusion, Medication

Difficulty: Moderate

Feedback
A.Nitrates often cause a heart rate greater than 100 beats per minute.
B.Isoproterenol is a drug that causes a heart rate greater than 100 beats per minute.
C.Nicotine is a drug that causes a heart rate greater than 100 beats per minute.
D.Digoxin is a drug that is known to cause bradycardia.
E.Procainamide is a drug that is known to cause bradycardia.

PTS: 1 CON: Perfusion | Medication

  1. ANS: 1, 3, 4, 5

Chapter number and title: 6, Assessing the Cardiovascular System

Chapter learning objective: N/A

Chapter page reference: 186

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Application [Applying]

Concept: Perfusion

Difficulty: Moderate

Feedback
A.Sinus bradycardia is a normal heart rhythm accompanied by a slow rate.
B.Atrial fibrillation is often the cause of an accelerated heart rate.
C.Heart block is a known cause for a heart rate less than 60 beats per minute.
D.Myocardial infarction is a known cause for a heart rate less than 60 beats per minute.
E.Hyperkalemia is a known cause for a heart rate less than 60 beats per minute.

PTS: 1 CON: Perfusion

  1. ANS: 1, 2, 3

Chapter number and title: 6, Assessing the Cardiovascular System

Chapter learning objective: N/A

Chapter page reference: 199

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Application [Applying]

Concept: Perfusion, Assessment

Difficulty: Moderate

Feedback
A.Mitral regurgitation is best auscultated as the apical area.
B.Mitral regurgitation is often described as blowing, harsh, or musical.
C.Mitral regurgitation may mask S1 .
D.Mitral stenosis, not regurgitation, is localized to a small area about the size of a quarter.
E.Aortic stenosis, not mitral regurgitation, is described as a rough, low-pitch sound.

PTS: 1 CON: Perfusion | Assessment

Chapter 07: Assessing the Peripheral-Vascular and Lymphatic System

Multiple Choice

Identify the choice that best completes the statement or answers the question.

____ 1. Which is a role of the peripheral-vascular (PV) system?

1)Transporting oxygen to all body organs
2)Transporting lymph to all body organs
3)Regulating the endocrine system
4)All of the above

____ 2. What is the role of the lymphatic system?

1)To move excess tissue fluid in a closed circuit with the cardiovascular system
2)To develop and maintain the immune system
3)To reabsorb fat and fat-soluble substances from the small intestine
4)All of the above

____ 3. What is the function of lymph nodes?

1)To drain lymph back to right lymphatic duct and thoracic duct
2)To filter microorganisms and foreign substances from lymph
3)To collect fluid from interstitial space and surrounding tissue
4)To secrete thymocytes that help with T-cell differentiation

____ 4. Lymphoid tissue is in greatest abundance at which age?

1)Infancy
2)School age
3)Adolescence
4)Adulthood

____ 5. Which event during pregnancy causes palmar erythema and spider telangiectasis?

1)Peripheral vasodilation
2)Increased leukocyte count
3)Decreased immunoglobulin G (IgG) concentrations
4)Increased number and size of lymph nodes

____ 6. Which factor contributes to older adults’ impaired ability to resist infection and overall lowered immunity?

1)Systemic vascular resistance decreases.
2)Venous elasticity decreases.
3)Lymph nodes become fibrotic and fatty.
4)Thymus shrinks.

____ 7. Which factors contribute to increased blood pressure (BP) in older patients from increased PV resistance?

1)Decreased lymph
2)Weakened medial wall
3)Increased wall elasticity
4)Fibrosis of intimal wall

____ 8. Which factors can contribute to the formation of edema?

1)High-salt meal
2)Exercise
3)Elevation of extremities
4)Excessive urination

____ 9. Intermittent claudication is indicative of which disease process?

1)Arterial insufficiency
2)Raynaud disease
3)Congestive heart failure
4)Venous insufficiency

____ 10. The hospitalized patient complains of pain in the right calf. The nurse notices red streaks along the leg, and it is warm and swollen. Based on this data which condition does the nurse suspect?

1)Arterial insufficiency
2)Venous insufficiency
3)Thrombophlebitis
4)Buerger disease

____ 11. The patient had a right mastectomy 2 years ago and now reports pain and swelling of the right arm. Based on this data, which does the nurse suspect?

1)Buerger disease
2)Arterial insufficiency
3)Obstruction of lymph flow
4)Myasthenia gravis

____ 12. Which is not a sign of venous insufficiency?

1)Thick skin
2)Poor wound healing
3)Rubor
4)Edema

____ 13. Which assessment findings are expected for a patient diagnosed with Raynaud disease?

1)Streaky redness, tenderness, and warmth along the course of a vein
2)Intermittent pain in calves upon ambulation
3)Gangrene of hands and fingers
4)Intermittent pallor and cyanosis of hands and fingers

____ 14. Which is the best location for palpation of pulses?

1)Over a bone
2)On soft tissue
3)Under a lymph node
4)On top of a lymph node

____ 15. The nurse palpates an older patient’s lower legs and notices an indentation of approximately 4 mm left by the fingertips, which disappears in about 10 seconds. How will the nurse document this edema in the medical record?

1)+1
2)+2
3)+3
4)+4

____ 16. While auscultating a patient’s neck, the nurse hears a soft, low-pitch, rushing sound. Which conclusion by the nurse is most accurate?

1)Narrowing of the internal or external jugular vein
2)Dilation of the internal or external jugular vein
3)Narrowing of the carotid or temporal artery
4)Dilation of the carotid or temporal artery

____ 17. Before taking a patient’s blood pressure (BP), which action by the nurse estimates the patient’s systolic pressure?

1)Weighing the patient
2)Inflating the BP cuff 20 mm above the point the radial pulse is occluded
3)Asking the patient about the last BP reading
4)Asking the patient’s age

____ 18. Which characteristic should be noted when assessing pulses?

1)Presence of a murmur
2)Split sound
3)Timing in cardiac cycle
4)Amplitude

____ 19. When auscultating the patient’s blood pressure (BP), what should the nurse do to avoid the auscultatory gap?

1)Take a palpable BP.
2)Inflate the cuff to 30 mm Hg greater than the point where the palpable pulse is obliterated.
3)Inflate the cuff to the point where the palpable pulse is obliterated.
4)Always inflate the cuff above 200 mm Hg pressure.

____ 20. What technique is appropriate when auscultating the central and peripheral arteries for bruits?

1)Use the bell of the stethoscope.
2)Use the diaphragm of the stethoscope.
3)Auscultate while the patient inhales deeply.
4)Palpate the radial pulse during auscultation.

____ 21. When assessing the central and peripheral arteries for bruits, what sound should normally be heard?

1)No sound
2)A swishing sound
3)S1 and S2
4)A murmur

____ 22. Which arterial pulses should be palpated medial to the biceps tendon?

1)Radial pulse
2)Ulnar pulse
3)Femoral pulse
4)Brachial pulse

____ 23. Which statement is true regarding the lymphatic system?

1)The lymphatic system is able to pump lymph independently of the cardiovascular system.
2)The lymphatic system pumps blood through the cardiovascular system.
3)The lymphatic system carries oxygen to the major organs.
4)The lymphatic system carries unoxygenated blood back to the heart.

____ 24. Which location will the nurse use to assess the posterior tibialis pulse?

1)The dorsum of the foot
2)The back of the knee
3)The apex of the heart
4)The ventral portion of the neck

____ 25. Which is considered an orthostatic drop in BP?

1)More than 20 mm Hg
2)More than 30 mm Hg
3)More than 40 mm Hg
4)More than 50 mm Hg

____ 26. Which lymph nodes are located in the anterior axillary fold?

1)Pectoral nodes
2)Horizontal nodes
3)Subclavian nodes
4)Supraclavicular nodes

____ 27. Which lymph nodes are located in the inguinal area?

1)Pectoral nodes
2)Horizontal nodes
3)Subclavian nodes
4)Suprascapular nodes

____ 28. Which lymph node is located below the clavicle?

1)Horizontal node
2)Subclavian node
3)Suprascapular node
4)Central node

____ 29. Which lymph node is located in the posterior axillary fold?

1)Horizontal node
2)Subclavian node
3)Suprascapular node
4)Central node

____ 30. Which lymph nodes are located deep in the axilla?

1)Pectoral nodes
2)Horizontal nodes
3)Subclavian nodes
4)Central nodes

____ 31. Which lymphatic tissue destroys microorganisms and foreign substances at the beginning of the digestive and respiratory tracts?

1)Tonsils
2)Peyer patches
3)Spleen
4)Thymus

____ 32. Which is described as clusters of non-capsulated lymph tissue found in the small intestines and appendix?

1)Tonsils
2)Peyer patches
3)Thymus
4)Epitrochlear nodes

____ 33. Which is lymphatic tissue that filters blood and produces lymphocytes and monocytes?

1)Peyer patches
2)Spleen
3)Thymus
4)Tonsils

____ 34. Which is lymphatic tissue in the thorax that forms antibodies in newborn and developing immune systems?

1)Tonsils
2)Spleen
3)Thymus
4)Epitrochlear nodes

____ 35. Which drains the hands and forearms of lymph?

1)Tonsils
2)Peyer’s patches
3)Spleen
4)Epitrochlear nodes

Completion

Complete each statement.

  1. A 30-mm systolic or ____________________-mm diastolic increase in blood pressure (BP) may indicate preeclampsia.

  1. Edema is documented when there is a difference in leg circumference of 1 cm above the ankle or ____________________ cm at the calf.

Chapter 07: Assessing the Peripheral-Vascular and Lymphatic System

Answer Section

MULTIPLE CHOICE

  1. ANS: 1

Chapter number and title: 7, Assessing the Peripheral-Vascular and Lymphatic System

Chapter learning objective: N/A

Chapter page reference: 204

Heading: Primary Functions

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Knowledge [Remembering]

Concept: Perfusion

Difficulty: Easy

Feedback
1The PV system is a branching network of vessels that transports oxygenated blood to all body organs and tissues and then returns it to the heart for reoxygenation in the lungs.
2The PV system does not transport lymph to all body organs.
3The PV system does not regulate the endocrine system.
4Not all of these statements refer to the role of the PV system.

PTS: 1 CON: Perfusion

  1. ANS: 4

Chapter number and title: 7, Assessing the Peripheral-Vascular and Lymphatic System

Chapter learning objective: N/A

Chapter page reference: 204

Heading: Primary Functions

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Knowledge [Remembering]

Concept: Immunity

Difficulty: Easy

Feedback
1The lymphatic system is responsible for the movement of lymph fluid in a close circuit with the cardiovascular system.
2The lymphatic system is responsible for the development and maintenance of the immune system.
3The lymphatic system is responsible for the reabsorption of fat and fat-soluble substance from the small intestine.
4The important functions of the lymphatic system include movement of lymph fluid in a closed circuit with the cardiovascular system, development and maintenance of the immune system, and reabsorption of fat and fat-soluble substances from the small intestine.

PTS: 1 CON: Immunity

  1. ANS: 2

Chapter number and title: 7, Assessing the Peripheral-Vascular and Lymphatic System

Chapter learning objective: N/A

Chapter page reference: 204

Heading: Primary Functions

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Knowledge [Remembering]

Concept: Immunity

Difficulty: Easy

Feedback
1Lymph nodes do not drain lymph back to the right lymphatic duct and thoracic duct.
2Lymph nodes filter microorganisms and foreign substances from lymph.
3Lymph nodes do not collect fluid from interstitial space and surrounding tissue.
4Lymph nodes do not secrete thymocytes that help with T-cell differentiation.

PTS: 1 CON: Immunity

  1. ANS: 2

Chapter number and title: 7, Assessing the Peripheral-Vascular and Lymphatic System

Chapter learning objective: N/A

Chapter page reference: 204

Heading: Developmental Considerations

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Comprehension [Understanding]

Concept: Immunity

Difficulty: Easy

Feedback
1Lymphoid tissue is abundant during infancy, but this is not when it is at the greatest abundance.
2Lymphatic tissue is at its most abundant during the school-age years, ages 6 to 10 years.
3Lymphatic tissue regresses to adult levels by puberty, or adolescence.
4Lymphatic tissue decreases in size with age.

PTS: 1 CON: Immunity

  1. ANS: 1

Feedback: Peripheral vasodilation occurs, which may lead to palmar erythema, an inflammatory redness of the palms, and to spider telangiectasis, a spider-like image on the skin caused by a branched group of dilated capillary blood vessels.

Chapter number and title: 7, Assessing the Peripheral-Vascular and Lymphatic System

Chapter learning objective: N/A

Chapter page reference: 205

Heading: Developmental Considerations

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Comprehension [Understanding]

Concept: Pregnancy

Difficulty: Easy

Feedback
1During pregnancy, peripheral vasodilation occurs, which can lead to palmar erythema and spider telangiectasis.
2An increased leukocyte count does not cause palmar erythema or spider telangiectasis.
3A decrease in IgG does not cause palmar erythema or spider telangiectasis.
4An increased number and size of lymphocytes does not cause palmar erythema or spider telangiectasis.

PTS: 1 CON: Pregnancy

  1. ANS: 3

Chapter number and title: 7, Assessing the Peripheral-Vascular and Lymphatic System

Chapter learning objective: N/A

Chapter page reference:

Heading: Developmental Considerations

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Comprehension [Understanding}

Concept: Immunity, Infection

Difficulty: Easy

Feedback
1A decreased systemic vascular resistance does not impair the ability to resist infection.
2Decreased venous elasticity does not impair the ability to resist infection.
3Lymph nodes become fibrotic and fatty, resulting in impaired ability to resist infection.
4A decreased thymus size does not impair the ability to resist infection.

PTS: 1 CON: Immunity | Infection

  1. ANS: 4

Chapter number and title: 7, Assessing the Peripheral-Vascular and Lymphatic System

Chapter learning objective: N/A

Chapter page reference: 205

Heading: Developmental Considerations

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Comprehension [Understanding]

Concept: Perfusion

Difficulty: Easy

Feedback
1Decreased lymph is not responsible for increased blood pressure.
2A weakened medial wall is not responsible for increased blood pressure.
3Increased wall elasticity is not responsible for increased blood pressure.
4Degenerative changes occur in the vascular system as part of the normal aging process. Fibrosis causes increased thickness in the intimal wall. Wall stiffness is caused by an accumulation of collagen and calcium in the intima and media. Elastic fibers of the media become thin and calcified. These changes dramatically decrease the flexibility and elasticity of the vessels and increase PV resistance.

PTS: 1 CON: Perfusion

  1. ANS: 1

Chapter number and title: 7, Assessing the Peripheral-Vascular and Lymphatic System

Chapter learning objective: N/A

Chapter page reference: 206

Heading: Assessment – History

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Comprehension [Understanding]

Concept: Perfusion

Difficulty: Easy

Feedback
1High-sodium or low-protein diets may cause edema.
2Exercise would improve venous return and decrease edema.
3Elevation of extremities would improve venous return and decrease edema.
4Excessive urination leads to dehydration, not edema.

PTS: 1 CON: Perfusion

  1. ANS: 1

Chapter number and title: 7, Assessing the Peripheral-Vascular and Lymphatic System

Chapter learning objective: N/A

Chapter page reference: 213

Heading: Assessment of the Peripheral-Vascular and Lymphatic Systems’ Relationship to Other Systems

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Comprehension [Understanding]

Concept: Perfusion

Difficulty: Easy

Feedback
1Calf pain with walking (intermittent claudication) is indicative of arterial insufficiency.
2Raynaud disease is not associated with intermittent claudication.
3Congestive heart failure not associated with intermittent claudication.
4Venous insufficiency is not associated with intermittent claudication.

PTS: 1 CON: Perfusion

  1. ANS: 3

Chapter number and title: 7, Assessing the Peripheral-Vascular and Lymphatic System

Chapter learning objective: N/A

Chapter page reference: 215

Heading: Assessment of the Peripheral-Vascular and Lymphatic Systems’ Relationship to Other Systems

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Application [Applying]

Concept: Perfusion, Infection, Inflammation

Difficulty: Moderate

Feedback
1Arterial insufficiency is not characterized by red streaks, warmth, edema, and pain in the calf.
2Venous insufficiency is not characterized by red streaks, warmth, edema, and pain in the calf.
3A warm, red, edematous extremity is indicative of thrombophlebitis.
4Buerger disease is not characterized by red streaks, warmth, edema, and pain in the calf.

PTS: 1 CON: Perfusion | Infection | Inflammation

  1. ANS: 3

Chapter number and title: 7, Assessing the Peripheral-Vascular and Lymphatic System

Chapter learning objective: N/A

Chapter page reference: 217-218

Heading: Assessment of the Peripheral-Vascular and Lymphatic Systems’ Relationship to Other Systems

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Application [Applying]

Concept: Female Reproduction

Difficulty: Moderate

Feedback
1Edema is not associated with Buerger disease.
2Edema is not associated with arterial insufficiency.
3Mastectomy with lymph node removal can cause lymphedema.
4Edema is not associated with myasthenia gravis.

PTS: 1 CON: Female Reproduction

  1. ANS: 3

Chapter number and title: 7, Assessing the Peripheral-Vascular and Lymphatic System

Chapter learning objective: N/A

Chapter page reference: 211

Heading: Physical Assessment

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Application [Applying]

Concept: Perfusion

Difficulty: Moderate

Feedback
1Venous insufficiency is marked by thick, leathery skin.
2Venous insufficiency is marked by poor wound-healing ability.
3Rubor is seen with arterial insufficiency.
4Venous insufficiency is marked by edema.

PTS: 1 CON: Perfusion

  1. ANS: 4

Chapter number and title: 7, Assessing the Peripheral-Vascular and Lymphatic System

Chapter learning objective: N/A

Chapter page reference: 215

Heading: Physical Assessment

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Application [Applying]

Concept: Perfusion

Difficulty: Moderate

Feedback
1Streaky redness, tenderness, and warmth along course of a vein is associated with thrombophlebitis.
2Intermittent pain in calves upon ambulation is associated with arterial insufficiency.
3Gangrene of hands and fingers may occur with Buerger disease.
4Raynaud phenomenon or Raynaud disease (a condition in which digital arteries respond excessively to vasospastic stimuli) causes episodic constriction of peripheral small arteries or arterioles.

PTS: 1 CON: Perfusion

  1. ANS: 1

Chapter number and title: 7, Assessing the Peripheral-Vascular and Lymphatic System

Chapter learning objective: N/A

Chapter page reference: 219

Heading: Physical Assessment

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Application [Applying]

Concept: Perfusion, Assessment

Difficulty: Moderate

Feedback
1Because arteries are elastic, if they are pushed into soft tissue, it will be difficult to palpate the pulse. Therefore, palpate arteries over bone.
2If the artery is pushed into the soft tissue, it becomes difficult to palpate.
3Pulses are not palpable under a lymph node.
4Pulses are not palpable on top of a lymph node.

PTS: 1 CON: Perfusion | Assessment

  1. ANS: 2

Chapter number and title: 7, Assessing the Peripheral-Vascular and Lymphatic System

Chapter learning objective: N/A

Chapter page reference: 218

Heading: Physical Assessment

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Application [Applying]

Concept: Perfusion

Difficulty: Moderate

Feedback
1+1: Slight pitting with about 2-mm depression that disappears rapidly. No visible distortion of extremity.
2+2: Deeper pitting with about 4-mm depression that disappears in 10 to 15 seconds. No visible distortion of extremity.
3+3: Depression of about 6 mm that lasts more than a minute. Dependent extremity looks swollen.
4+4: Very deep pitting with about 8-mm depression that lasts 2 to 3 minutes. Dependent extremity is grossly distorted.

PTS: 1 CON: Perfusion

  1. ANS: 3

Chapter number and title: 7, Assessing the Peripheral-Vascular and Lymphatic System

Chapter learning objective: N/A

Chapter page reference: 223

Heading: Physical Assessment

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Analyzing [Analysis]

Concept: Perfusion

Difficulty: Moderate

Feedback
1A bruit doesn’t occur by a narrowing of the internal or external jugular vein.
2A bruit doesn’t occur by a dilation of the internal or external jugular vein.
3A bruit is a low-pitch sound. A bruit in the temporal or carotid artery signifies narrowing of the artery.
4A bruit doesn’t occur by a dilation of the internal or external carotid artery.

PTS: 1 CON: Perfusion

  1. ANS: 2

Chapter number and title: 7, Assessing the Peripheral-Vascular and Lymphatic System

Chapter learning objective: N/A

Chapter page reference: 223

Heading: Physical Assessment

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Application [Applying]

Concept: Perfusion, Assessment

Difficulty: Moderate

Feedback
1Weighing the patient does not estimate the systolic pressure.
2Estimate systolic BP by applying the cuff and palpating the radial pulse. Inflate the cuff until the pulse disappears; this point is estimated systolic pressure. Deflate the cuff and wait 1 minute before taking BP.
3Asking the patient about the last BP reading does not estimate systolic pressure.
4Asking the patient’s age does not estimate the systolic pressure.

PTS: 1 CON: Perfusion | Assessment

  1. ANS: 4

Chapter number and title: 7, Assessing the Peripheral-Vascular and Lymphatic System

Chapter learning objective: N/A

Chapter page reference: 219

Heading: Physical Assessment

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Comprehension [Understanding]

Concept: Perfusion

Difficulty: Easy

Feedback
1A murmur is a characteristic of heart sounds.
2Split sounds are a characteristic of heart sounds.
3Timing of the cardiac cycle is a characteristic of heart sounds.
4Amplitude reflects the strength of the pulse.

PTS: 1 CON: Perfusion

  1. ANS: 2

Chapter number and title: 7, Assessing the Peripheral-Vascular and Lymphatic System

Chapter learning objective: N/A

Chapter page reference: 223

Heading: Physical Assessment

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Application [Applying]

Concept: Perfusion, Assessment

Difficulty: Moderate

Feedback
1Taking a palpable BP will not avoid the auscultatory gap.
2Rapidly and steadily inflate the cuff 30 mm Hg higher than patient’s estimated systolic BP.
3Inflating the cuff to the point where the palpable pulse is obliterated will not avoid the auscultatory gap.
4Always inflating the cuff above 200 mm Hg pressure will not avoid the auscultatory gap.

PTS: 1 CON: Perfusion | Assessment

  1. ANS: 1

Chapter number and title: 7, Assessing the Peripheral-Vascular and Lymphatic System

Chapter learning objective: N/A

Chapter page reference: 223

Heading: Physical Assessment

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Application [Applying]

Concept: Perfusion, Assessment

Difficulty: Moderate

Feedback
1When auscultating the central and peripheral arteries, the bell portion of the stethoscope should be used to identify bruits because they are low-pitch sounds.
2The diaphragm of the stethoscope is not used to auscultate for bruits.
3The patient is not asked to inhale deeply when auscultating for bruits.
4The nurse does not palpate the radial pulse when auscultating for bruits.

PTS: 1 CON: Perfusion | Assessment

  1. ANS: 1

Chapter number and title: 7, Assessing the Peripheral-Vascular and Lymphatic System

Chapter learning objective: N/A

Chapter page reference: 223

Heading: Physical Assessment

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Comprehension [Understanding]

Concept: Perfusion, Assessment

Difficulty: Easy

Feedback
1When assessing the central and peripheral arteries for bruits, no vascular sounds should be heard on auscultation.
2When assessing the central and peripheral arteries for bruits, a swishing sound should not be heard on auscultation.
3When assessing the central and peripheral arteries for bruits, S1 and S2 sounds should not be heard on auscultation.
4When assessing the central and peripheral arteries for bruits, a murmur sound should not be heard on auscultation.

PTS: 1 CON: Perfusion | Assessment

  1. ANS: 4

Chapter number and title: 7, Assessing the Peripheral-Vascular and Lymphatic System

Chapter learning objective: N/A

Chapter page reference: 214

Heading: Physical Assessment – Anatomical Landmarks

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Comprehension [Understanding]

Concept: Assessment, Perfusion

Difficulty: Easy

Feedback
1The radial pulse is not palpated medial to the biceps tendon.
2The ulnar pulse is not palpated medial to the biceps tendon.
3The femoral pulse is not palpated medial to the biceps tendon.
4The brachial pulse should be palpated medial to the biceps tendon. The brachial artery supplies the humerus as well as the muscles and skin of the area.

PTS: 1 CON: Assessment | Perfusion

  1. ANS: 1

Chapter number and title: 7, Assessing the Peripheral-Vascular and Lymphatic System

Chapter learning objective: N/A

Chapter page reference: 204

Heading: Primary Functions

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Comprehension [Understanding]

Concept: Immunity

Difficulty: Easy

Feedback
1The lymphatic system has no pumping mechanism of its own, so it depends on the cardiovascular system, contraction of smooth muscles within lymphatic vessels, and skeletal muscle contraction to pump lymph throughout the body.
2The lymphatic system does not pump blood through the cardiovascular system.
3The lymphatic system does not carry oxygen to the major organs.
4The lymphatic system does not carry unoxygenated blood back to the heart.

PTS: 1 CON: Immunity

  1. ANS: 1

Chapter number and title: 7, Assessing the Peripheral-Vascular and Lymphatic System

Chapter learning objective: N/A

Chapter page reference: 214

Heading: Physical Assessment – Anatomical Landmarks

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Knowledge [Remembering]

Concept: Perfusion, Assessment

Difficulty: Easy

Feedback
1The posterior tibialis pulse supplies the backs of the legs and ankles.
2The posterior tibialis pulse does not supply the back of the knees.
3The posterior tibialis pulse does not supply the apex of the heart.
4The posterior tibialis pulse does not supply the ventral portion of the neck.

PTS: 1 CON: Perfusion | Assessment

  1. ANS: 1

Chapter number and title: 7, Assessing the Peripheral-Vascular and Lymphatic System

Chapter learning objective: N/A

Chapter page reference: 224

Heading: Physical Assessment

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Comprehension [Understanding]

Concept: Perfusion, Assessment

Difficulty: Easy

Feedback
1Decrease in systolic BP of 20 mm Hg or more and drop in diastolic BP on standing accompanied by a rise in pulse rate is orthostatic hypotension.
2Orthostatic hypotension is defined as a drop in systolic BP of 20 mm Hg or more and not 30 mm Hg.
3Orthostatic hypotension is defined as a drop in systolic BP of 20 mm Hg or more and not 40 mm Hg.
4Orthostatic hypotension is defined as a drop in systolic BP of 20 mm Hg or more and not 50 mm Hg.

PTS: 1 CON: Perfusion | Assessment

  1. ANS: 1

Chapter number and title: 7, Assessing the Peripheral-Vascular and Lymphatic System

Chapter learning objective: N/A

Chapter page reference: 214

Heading: Physical Assessment – Anatomical Landmarks

Integrated Processes: Physiological Integrity: Physiological Adaptation

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Comprehension [Understanding]

Concept: Immunity, Assessment

Difficulty: Easy

Feedback
1Pectoral nodes are located in the anterior axillary fold.
2Horizontal nodes are not located in the anterior axillary fold.
3Subclavian nodes are not located in the anterior axillary fold.
4Supraclavicular nodes are not located in the anterior axillary fold.

PTS: 1 CON: Immunity | Assessment

  1. ANS: 2

Chapter number and title: 7, Assessing the Peripheral-Vascular and Lymphatic System

Chapter learning objective: N/A

Chapter page reference: 214

Heading: Physical Assessment – Anatomical Landmarks

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Comprehension [Understanding]

Concept: Immunity

Difficulty: Easy

Feedback
1Pectoral nodes are not located in the inguinal area.
2Horizontal nodes are located in the inguinal area.
3Subclavian nodes are not located in the inguinal area.
4Suprascapular nodes are not located in the inguinal area.

PTS: 1 CON: Immunity

  1. ANS: 2

Chapter number and title: 7, Assessing the Peripheral-Vascular and Lymphatic System

Chapter learning objective: N/A

Chapter page reference: 214

Heading: Physical Assessment – Anatomical Landmarks

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Comprehension [Understanding]

Concept: Immunity

Difficulty: Easy

Feedback
1The horizontal node is not located below the clavicle.
2The subclavian node is located below the clavicle.
3The suprascapular node is not located below the clavicle.
4The central node is not located below the clavicle.

PTS: 1 CON: Immunity

  1. ANS: 3

Chapter number and title: 7, Assessing the Peripheral-Vascular and Lymphatic System

Chapter learning objective: N/A

Chapter page reference: 214

Heading: Physical Assessment – Anatomical Landmarks

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Comprehension [Understanding]

Concept: Immunity

Difficulty: Easy

Feedback
1The horizontal node is not located in the posterior axillary fold.
2The subclavian node is not located in the posterior axillary fold.
3The suprascapular node is located in the posterior axillary fold.
4The central node is not located in the posterior axillary fold.

PTS: 1 CON: Immunity

  1. ANS: 4

Chapter number and title: 7, Assessing the Peripheral-Vascular and Lymphatic System

Chapter learning objective: N/A

Chapter page reference: 214

Heading: Physical Assessment – Anatomical Landmark

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Comprehension [Understanding]

Concept: Immunity

Difficulty: Easy

Feedback
1The pectoral nodes are not located deep in the axilla.
2The horizontal nodes are not located deep in the axilla.
3The subclavian nodes are not located deep in the axilla.
4The central nodes are located deep in the axilla.

PTS: 1 CON: Immunity

  1. ANS: 1

Chapter number and title: 7, Assessing the Peripheral-Vascular and Lymphatic System

Chapter learning objective: N/A

Chapter page reference: 211

Heading: Physical Assessment

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Comprehension [Understanding]

Concept: Immunity

Difficulty: Easy

Feedback
1The tonsils are lymphatic tissue that destroys microorganisms and foreign substances at the beginning of the digestive and respiratory tracts.
2Peyer patches are not lymphatic tissue that destroys microorganisms and foreign substances at the beginning of the digestive and respiratory tracts.
3The spleen is not lymphatic tissue that destroys microorganisms and foreign substances at the beginning of the digestive and respiratory tracts.
4The thymus is not lymphatic tissue that destroys microorganisms and foreign substances at the beginning of the digestive and respiratory tracts.

PTS: 1 CON: Immunity

  1. ANS: 2

Chapter number and title: 7, Assessing the Peripheral-Vascular and Lymphatic System

Chapter learning objective: N/A

Chapter page reference: 215-216

Heading: Physical Assessment

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Comprehension [Understanding]

Concept: Immunity

Difficulty: Easy

Feedback
1Tonsils are not clusters of non-capsulated lymph tissue found in the small intestines and appendix.
2Peyer patches are described as clusters of non-capsulated lymph tissue found in the small intestines and appendix.
3The thymus is not described as clusters of non-capsulated lymph tissue found in the small intestines and appendix.
4Epitrochlear nodes are not clusters of non-capsulated lymph tissue found in the small intestines and appendix.

PTS: 1 CON: Immunity

  1. ANS: 2

Chapter number and title: 7, Assessing the Peripheral-Vascular and Lymphatic System

Chapter learning objective: N/A

Chapter page reference: 212

Heading: Physical Assessment

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Comprehension [Understanding]

Concept: Immunity

Difficulty: Easy

Feedback
1Peyer patches are not lymphatic tissue that filters blood and produce lymphocytes and monocytes.
2The spleen is lymphatic tissue that filters blood and produces lymphocytes and monocytes.
3The thymus is not lymphatic tissue that filters blood and produces lymphocytes and monocytes.
4Tonsils are not lymphatic tissue that filters blood and produce lymphocytes and monocytes.

PTS: 1 CON: Immunity

  1. ANS: 3

Chapter number and title: 7, Assessing the Peripheral-Vascular and Lymphatic System

Chapter learning objective: N/A

Chapter page reference: 204

Heading: Developmental Considerations

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Comprehension [Understanding]

Concept: Immunity

Difficulty: Easy

Feedback
1The tonsils are not lymphatic tissue in the thorax that forms antibodies in newborn and developing immune systems.
2The spleen is not lymphatic tissue in the thorax that forms antibodies in newborn and developing immune systems.
3The thymus is lymphatic tissue in the thorax that forms antibodies in newborn and developing immune systems.
4Epitrochlear nodes are not lymphatic tissue in the thorax that forms antibodies in newborn and developing immune systems.

PTS: 1 CON: Immunity

  1. ANS: 4

Chapter number and title: 7, Assessing the Peripheral-Vascular and Lymphatic System

Chapter learning objective: N/A

Chapter page reference: 222

Heading: Physical Assessment

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Comprehension [Understanding]

Concept: Perfusion

Difficulty: Easy

Feedback
1The tonsils do not drain the hands and forearms of lymph.
2Peyer patches does not drain the hands and forearms of lymph.
3The spleen does not drain the hands and forearms of lymph.
4Epitrochlear nodes drain the hands and forearms of lymph.

PTS: 1 CON: Perfusion

COMPLETION

  1. ANS:

15

Feedback: A 30-mm systolic or 15-mm diastolic increase in BP may indicate preeclampsia.

Chapter number and title: 7, Assessing the Peripheral-Vascular and Lymphatic System

Chapter learning objective: N/A

Chapter page reference: 205

Heading: Developmental Considerations

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Comprehension [Understanding]

Concept: Perfusion, Pregnancy

Difficulty: Easy

PTS: 1 CON: Perfusion | Pregnancy

  1. ANS:

2

Feedback: Edema is documented when there is a difference in leg circumference of 1 cm above the ankle or 2 cm at the calf.

Chapter number and title: 7, Assessing the Peripheral-Vascular and Lymphatic System

Chapter learning objective: N/A

Chapter page reference: 217

Heading: Physical Assessment

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Comprehension [Understanding]

Concept: Perfusion

Difficulty: Easy

PTS: 1 CON: Perfusion

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